This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

THE THERAPY PROCESS
Counseling is a collaborative process designed to help you identify goals, improve coping skills, and address concerns affecting your well-being. Counseling outcomes cannot be guaranteed and may involve discussing difficult experiences or emotions. Participation is voluntary, and you may discontinue services at any time. Treatment goals and progress will be reviewed throughout the counseling process.

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QUALIFICATIONS OF PROVIDERS

• Please visit our website at https://www.sagehealingcounseling.com/team for information on our providers qualifications.

TELEHEALTH SERVICES
Telehealth services are provided using secure, HIPAA-compliant technology. To participate, you will need a reliable internet connection and a device with audio and video capabilities. Your Provider will give you instructions on how to access and use the telehealth platform. If telehealth is determined to be inappropriate for your needs, your Provider will discuss alternative options or referrals.

Risks of Telehealth:

Telehealth services involve certain risks and limitations, including potential privacy and confidentiality risks despite the use of secure, HIPAA-compliant platforms. Technical issues such as internet, audio, or video disruptions may occur and may require the use of an agreed-upon backup method of communication, such as a phone call. Telehealth may not be appropriate for crisis or emergency situations, and your Provider may not be able to offer immediate in-person assistance. You agree to provide your current location at the start of each session and to work with your Provider to establish a safety plan that includes local emergency resources.

Benefits of Telehealth:

Telehealth can increase access to care by reducing barriers such as transportation, distance, scheduling challenges, illness, or inclement weather. It also offers the convenience of attending sessions from a location of your choice.

Client Responsibilities and Recommendations:

To support the effectiveness and confidentiality of telehealth services, you agree to participate in sessions from a private location, refrain from recording sessions without your Provider’s written consent, provide your current physical location at the start of each session, and ensure you have a charged device and reliable internet connection.

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CONFIDENTIALITY

Your Provider will not disclose your personal health information without your written authorization, except as permitted or required by law. When disclosure is required, only the minimum necessary information will be shared.

Exceptions to Confidentiality:

• Coordination of care, when appropriate.

• Professional consultations conducted in accordance with privacy laws.

• Emergency situations

• Unethical or inappropriate conduct by another healthcare provider.

• Suspected abuse or neglect of a child, elderly individual, or person with a disability.

• Serious risk of harm to yourself or others.

• Court orders or other legal requirements.

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NO RECORDING POLICY

To protect the privacy and confidentiality of all parties, audio, video, or photographic recording of therapy sessions is strictly prohibited unless prior written consent has been obtained from both the clinician and Sage Healing Counseling Services, PLLC. Unauthorized recording may result in the termination of services, as permitted by applicable law and professional ethics.

 

RECORD KEEPING
Your Provider is required to maintain records of services provided in accordance with applicable laws and professional standards. Records are stored in a secure electronic health record system. While reasonable measures are being taken to protect your information, no electronic system can guarantee complete security.

Record Retention

Your Provider retains records in accordance with Texas law and professional regulations:

• Adults: Records are maintained for at least 7 years from the date of last service.

• Minors: Records are maintained for at least 7 years from the date the minor reaches age 18 (typically until age 25).

After this period, records may be securely destroyed in accordance with applicable laws and policies.

COMMUNICATION

Email and text messaging are not secure methods of communication and should not be used for clinical emergencies. Secure messaging through the client portal on TherapyPortal.com is preferred. To maintain professional boundaries and confidentiality, providers do not communicate with clients through social media or public review platforms.

Social Media and Online Platforms
To protect your confidentiality and maintain professional boundaries, your Provider does not communicate with clients through social media, public platforms, or review sites. If you choose to follow your Provider's professional accounts or leave a public review, your Provider will not interact with or respond to your account to protect your privacy.

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FEES AND PAYMENT FOR SERVICES
You are responsible for payment of all services and applicable fees. Fees will be provided to you prior to the start of services.

Insurance and Benefits Verification
You are responsible for providing accurate insurance information. While benefits may be verified as a courtesy, verification is not a guarantee of payment. You are ultimately responsible for any charges, including copays, deductibles, coinsurance, and services not covered by your insurance plan.

Payment and Balances
Payment is due at the time of service unless prior arrangements have been made. If you are unable to pay, you should notify your Provider as soon as possible to discuss potential options, such as a payment plan or referral to lower-cost services.

Accounts with an outstanding balance for more than 30 business days may result in suspension or termination of services and may be referred to a collections agency, as permitted by law.

Administrative and Professional Fees
Additional fees may apply for non-clinical services, including but not limited to:

• Letters, forms, or reports requested by you

• Consultation with outside professionals (beyond standard coordination of care)

• Preparation, travel, and attendance related to legal proceedings

Payment Methods
You are required to keep a valid credit or debit card on file. This card will be charged for services and any applicable fees unless other arrangements have been made in advance. You are responsible for ensuring your payment information is current and has sufficient funds to cover charges.